What is the management of upper gastrointestinal bleed?

Management of Upper Gastrointestinal Bleeding

The management of upper gastrointestinal bleeding requires immediate resuscitation, risk stratification, early endoscopy within 24 hours, combination endoscopic therapy for high-risk lesions, and high-dose proton pump inhibitor therapy for 3 days following successful endoscopic hemostasis. 1, 2, 3

Initial Assessment and Resuscitation

• Immediate fluid resuscitation with crystalloids is critical for patients with hemodynamic instability to restore end-organ perfusion and tissue oxygenation 1, 3
• Blood transfusion should be initiated at a hemoglobin threshold of <80 g/L for patients without cardiovascular disease, with a higher threshold for those with cardiovascular disease 1, 3
• Nasogastric tube placement can be considered as findings may have prognostic value, with bright blood in the aspirate being an independent predictor of rebleeding 1, 3
• High-risk patients should be admitted to a monitored setting for at least the first 24 hours 1

Risk Stratification

• The Glasgow Blatchford score should be used to identify patients at very low risk (score ≤1) who may not require hospitalization or inpatient endoscopy 1, 2, 3
• Risk factors for rebleeding and mortality include age >60 years, poor overall health status, melena, fresh red blood in emesis or nasogastric aspirate, shock, and elevated urea, creatinine, or serum aminotransferase levels 1, 3

Pre-Endoscopic Management

• Intravenous proton pump inhibitors should be started immediately upon presentation with upper GI bleeding 1, 2
• For suspected variceal bleeding in patients with cirrhosis, initiate vasoactive drug therapy (terlipressin, somatostatin, or octreotide) as soon as bleeding is suspected 1
• Administer antibiotic prophylaxis in patients with cirrhosis and suspected variceal bleeding (ceftriaxone or norfloxacin) 1
• Prokinetic agents (erythromycin) can be administered before endoscopy to improve visualization 4

Endoscopic Management

• Endoscopy should be performed within 24 hours of presentation for most patients with upper GI bleeding 1, 2, 3
• Consider earlier endoscopy (within 12 hours) for high-risk patients with hemodynamic instability 1
• Combination endoscopic therapy is recommended for high-risk stigmata 1, 2, 3:
  • Injection plus thermal coagulation is superior to either treatment alone 1
  • Endoscopic clips are effective for hemostasis 1, 2
  • Epinephrine injection alone is not recommended 1
• For recurrent bleeding after initial endoscopic therapy, repeat endoscopic therapy is recommended 1
• TC-325 (hemostatic powder) can be used as temporizing therapy, but not as sole treatment, in patients with actively bleeding ulcers 1

Pharmacological Management

• High-dose PPI therapy (intravenous loading dose followed by continuous infusion) should be administered for 3 days in patients with high-risk stigmata who have undergone successful endoscopic therapy 1, 2, 3
• Continue oral PPI therapy twice daily through 14 days after the initial 3 days of treatment, then once daily for a duration that depends on the nature of the bleeding lesion 1, 2
• For variceal bleeding, continue vasoactive drugs and antibiotics for 3-5 days 1

Post-Endoscopic Care

• High-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis 1, 3
• Patients at low risk after endoscopy can be fed within 24 hours 1, 2
• All patients with bleeding peptic ulcers should be tested for Helicobacter pylori and receive eradication therapy if infection is present 1, 2, 3
• Testing for H. pylori during acute bleeding may have increased false-negative rates; confirmatory testing outside the acute context may be necessary 1

Management of Recurrent Bleeding

• For recurrent bleeding, repeat endoscopic therapy is the first-line approach 1, 5
• If endoscopic therapy fails, consider:
  • Transcatheter arterial embolization 6
  • Surgical intervention as a last resort 5, 7
• For recurrent variceal bleeding, consider transjugular intrahepatic portosystemic shunt (TIPS) 1, 7

Secondary Prophylaxis

• For patients requiring NSAIDs, a PPI with a cyclooxygenase-2 inhibitor is preferred to reduce rebleeding 1, 2
• Patients requiring secondary cardiovascular prophylaxis should restart acetylsalicylic acid (ASA) as soon as cardiovascular risks outweigh gastrointestinal risks (usually within 7 days) 1, 3
• ASA plus PPI therapy is preferred over clopidogrel alone to reduce rebleeding 1, 3
• PPI therapy is recommended for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy 1, 2, 3

Special Considerations

• In patients with cirrhosis and severe ascites, use non-selective beta blockers with caution and avoid high doses 1
• Consider discontinuing non-selective beta blockers in patients with progressive hypotension (systolic BP <90 mmHg) or acute conditions like bleeding, sepsis, or acute kidney injury 1
• If the patient remains hemodynamically unstable after initial resuscitation (shock index >1), consider urgent CT angiography to localize bleeding before planning endoscopic or radiological therapy 1, 8